Critical appraisal¹ 

Evaluation, limitations & suggestions for improvements

The previous review is noted and the points raised are agreed with, in addition I would add:

The interesting feature of this case is its educational value in thinking of accessory bones in your differential diagnosis. The history and examination is briefly but adequately explained. The radiographs are clear and support the rhetoric of the case report as well as allowing the reader to make their own interpretation.  The discussion of the case is limited and referencing is sparse. I would like to see a more in depth discussion of methods to distinguish between normal anatomical variants and acute injury.  Perhaps a diagnostic checklist or algorithm could be suggested which would increase the educational value of the article.

In summery: an interesting case with educational value worthy of publication.

References

Critical appraisal method adapted from:

 1.                   Jackson R, Ameratunga S, Broad J, Connor J, Lethaby A, Robb G, et al. The GATE frame: critical appraisal with pictures. Evidence Based Medicine. 2006 Apr 1;11(2):35 -38.

Adequacy of reporting as per checklist from :

2.                   Sorinola O, Olufowobi O, Coomarasamy A, Khan KS. Instructions to authors for case reporting are limited: A review of a core journal list. BMC Med Educ. 4:4-4.

Foundation trainee & Sports scientist

This case is of interest both for the unusual nature of the findings and also for the educational benefit. Accessory ossicles are most often found associated with the feet and ankles. As, the author points out, just one case of a radial styolid accessory ossicle is found in medline. It is right to say that the rarity of findings makes misdiagnosis possible and inappropriate treatment likely.

The radiographs presented are quite clear and easy to view.

The paper could be expanded for educational benefit. The accessory ossicle is shown in figures 1b and 1c  clearly. The proximal surface of these ossicles has a clearly demarked, smooth cortex. This would not be expected in an acute fracture. A further educational point could therefore be made that even if you don't know of rare anatomical variants, by careful inspection it is possible to distinguish between an acute injury requiring treatment and a well corticated old fragment or variant not needing further intervention.

I have worked in trauma and orthopaedics for several years. I regularly teach students.